Taking medicine on time seems simple, is anything but

University of Houston pharmaceutical health outcomes and policy researcher Susan Abughosh has received $459,000 from the National Institutes of Health to help patients with diabetes and high blood pressure stick to their medication schedules. Abughosh will add customized motivational interviewing conversations between patients and UH pharmacy students to help patients take their meds on time.

"In pilot work, our team has demonstrated improvements in adherence through a pharmacy student telephone MI intervention. Pharmacy students have the knowledge base and training to provide comparable services to pharmacists at a lower cost and can be a valuable resource to implement such interventions," said Abughosh.

For the first year of the three-year grant, her team will use group-based trajectory models to identify medication refill patterns of the group of approximately 15,000 patients, all of whom are prescribed either an angiotensin converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) to keep their conditions in check. Those who do well and adhere to schedules will not be needed for the second year of the study, the period in which the one-on-one conversations take place.

Before the phone conversations begin, Abughosh will review the prior year's patient adherence patterns and train the students in MI. The motivational interviewing telephone intervention will be customized by the past adherence patterns for a more tailored approach.

Barriers to adherence

Poor adherence remains a significant barrier to achieving full effectiveness and optimal long-term outcomes in the use of medication and is a significant problem among elderly patients with multiple chronic conditions, said Abughosh.

The difficulty in taking medicines on schedule arises for many different reasons. Examples of such barriers include low expectation of the treatment, fear of side effects, cost or transportation issues and forgetfulness. As these barriers vary by patient, an intervention tailored by past adherence patterns can help identify and address the patient-specific barrier and prove more influential in enhancing medication adherence.

Abughosh chose to study patients with diabetes and high blood pressure, known as the "deadly duet" of disease combinations that can bring on a heart attack. "Implementation of this intervention will enhance medication adherence among nonadherent elderly patients who are at a high risk of developing microvascular and macrovascular complications of diabetes," said Abughosh.

With the expected morbidity and mortality that accompanies poor medication adherence, effective interventions could translate into significant improvements in health and subsequent cost savings in a financially overburdened health care system.

The training

Once the nonadherent patients are determined and their past patterns of use depicted with trajectory modeling, they will be randomized to an intervention and control group. Project consultant Marcia Holstad of the Emory University School of Nursing, a certified MI trainer, will assist Abughosh in teaching motivational interviewing skills to UH College of Pharmacy students who will make the phone calls during their six-week rotation at health care provider Cigna Healthspring in north Houston.

"Motivational interviewing is a way to talk to patients in a collaborative manner, and it has been shown to improve medication adherence. It is very powerful," said Abughosh. MI includes asking open-ended questions, positive reinforcement and expressing empathy and understanding.

Monthly follow-up calls will be carried out for six months. Post intervention refill data will be evaluated to assess the intervention effectiveness in improving adherence.

"The project will formulate a strong adherence research team at University of Houston that will be instrumental in implementing customized innovative interventions to improve medication adherence and subsequent health outcomes," said Abughosh.